Should apixaban (eliquis) be stopped before a dental extraction?

Apixaban Does NOT Need to Be Stopped Before Dental Extraction

For routine dental extractions, apixaban should be continued without interruption, as dental procedures are classified as minimal bleeding risk with appropriate local hemostatic measures. 1

Evidence-Based Classification

The American College of Chest Physicians 2022 guidelines explicitly categorize minor dental procedures (dental extractions, restorations, prosthetics, endodontics), dental cleanings, and fillings as minimal-bleed-risk procedures with an approximate 30-day risk of major bleeding of 0%. 1 This classification places dental extractions in the same category as minor dermatologic procedures and cataract surgery—procedures where anticoagulation continuation is standard practice.

Recommended Management Protocol

Continue Apixaban Without Interruption

• No preoperative discontinuation is required for routine dental extractions 1
• The minimal bleeding risk designation means procedures can be safely performed with residual anticoagulant effect present 1
• This approach avoids the thromboembolic risk associated with unnecessary anticoagulation interruption 1

Essential Local Hemostatic Measures

• Apply gelatin sponge or similar hemostatic agents to extraction sockets 2
• Use suturing when appropriate to achieve primary closure 2
• Provide compression with gauze for 30 minutes post-extraction 2
• Prescribe tranexamic acid mouthwash (5% solution, 10 mL four times daily for 2 days) if additional hemostatic support is needed 2

When to Consider Holding Apixaban

Only for complex oral surgery procedures that exceed simple extractions should you consider interruption:

High-Risk Oral Surgery (Rare in General Dentistry)

• Multiple extractions (>3 teeth) with extensive bone removal 2
• Surgical procedures in highly vascular areas requiring extensive tissue manipulation 1
• If holding is necessary: Stop apixaban 48 hours before surgery in patients with normal renal function (CrCl >50 mL/min) 3
• For impaired renal function (CrCl 30-50 mL/min): Extend to 72 hours 4, 5

Critical Pitfalls to Avoid

Do NOT Routinely Discontinue Apixaban

• Meta-analysis evidence demonstrates no significant difference in bleeding risk between patients continuing versus discontinuing oral anticoagulation for dental extractions (RR 1.31,95% CI 0.79-2.14, p>0.05) 6
• Unnecessary interruption exposes patients to stroke and thromboembolism risk without meaningful bleeding reduction 1

Do NOT Use Bridging Anticoagulation

• Heparin bridging is explicitly not recommended and increases major bleeding risk without reducing thrombotic events 4, 7
• The rapid offset and onset of apixaban (half-life 7-8 hours) makes bridging unnecessary even when interruption is required 4

Do NOT Rely on Laboratory Monitoring

• Standard coagulation tests (INR, aPTT) are not useful for monitoring apixaban effect 5, 7
• Routine measurement of apixaban levels before dental procedures is not indicated when following recommended protocols 4, 5

Post-Extraction Management

• Continue apixaban at the regular dose immediately after the procedure 1
• Instruct patients to avoid vigorous rinsing for 24 hours 2
• Provide clear written and verbal post-operative bleeding instructions 2
• Most bleeding episodes occur within the first 30 minutes and respond to local measures (compression with gauze) 2, 8

Renal Function Considerations

While dental extractions don't require apixaban interruption, always assess renal function as it affects drug clearance:

• Apixaban has 25% renal clearance, making it less dependent on kidney function than dabigatran 4
• For the rare complex oral surgery requiring interruption, patients with CrCl 30-50 mL/min need extended hold times (72 hours vs 48 hours) 4, 5